PATIENT HISTORY FORM

NAME OF HOSPITAL: HOSP. CODE:

ADDRESS: HEALTH REC. NO.
SR. CITIZEN NO. CLINICAL COVER SHEET OLD HEALTH REC. NO.
PATIENT’S NAME: (Last) (Given) (Middle) WARD/ROOM/BED/SERVICE

PERMANENT ADDRESS: TEL. NO. SEX CIVIL STATUS

[ ] MALE [ ]S [ ]D [ ] SEP [ ] C
[ ] FEMALE [ ]W [ ]M [ ]N
BIRTHDATE AGE BIRTHPLACE NATIONALITY RELIGION OCCUPATION

ADMISSION DISCHARGE TOTAL NO. ADMITTING PHYSICIAN

DATE: DATE: OF DAYS
TIME: TIME:
ADMITTING CLERK ATTENDING PHYSICIAN/SIGNITURE

TYPE OF ADMISSION: REFERRED BY:

[ ] NEW [ ] OLD [ ] FORMER OPD (Physician/Agency)
SOCIAL SERVICE CLASSIFICIATION [ ]A [ ]B [ ] C1 [ ] C2 [ ] C3 [ ]D
HEALTH INSURANCE NAME: TYPE OF INSURANCE COVERAGE:

DATA FURNISHED BY ADDRESS OF INFORMANT RELATION TO PATIENT

CURRENT MEDICATIONS
Drug allergies: ❑ No ❑ Yes To what?
Please list any medications that you are now taking. Include non-prescription medications & vitamins or supplements:
Name of drug Dose (include strength & number of pills per day) How long have you been taking this?
1.
2.
3.
4.
5.

PAST MEDICAL HISTORY

Do you now or have you ever had:

❑ Diabetes ❑ Heart murmur ❑ Crohn’s disease

❑ High blood pressure ❑ Pneumonia ❑ Colitis
❑ High cholesterol ❑ Pulmonary embolism ❑ Anemia
❑ Hypothyroidism ❑ Asthma ❑ Jaundice
❑ Goiter ❑ Emphysema ❑ Hepatitis
❑ Cancer (type) _________________ ❑ Stroke ❑ Stomach or peptic ulcer
❑ Leukemia ❑ Epilepsy (seizures) ❑ Rheumatic fever
❑ Psoriasis ❑ Cataracts ❑ Tuberculosis
❑ Angina ❑ Kidney disease ❑ HIV/AIDS
❑ Heart problems ❑ Kidney stones

Other medical conditions (please list):

PERSONAL HEALTH HISTORY
HEIGHT WEIGHT
Have you ever had or have you now: (please check at right of each item and if yes, indicate year of first occurrence)
Yes No Year Yes No Year Yes No Year Yes No Year
High blood pressure Hay fever Jaundice or hepatitis Kidney stones

Rheumatic fever Allergy injection Rectal disease Protein or blood in

therapy urine
Arthritis Severe or recurrent Hearing loss
Heart trouble abdominal pain
Serious head injury Hernia Sinusitis
Pain or pressure in
chest
Frequent or severe Easy fatigability Severe menstrual
Shortness of breath headache cramps
Dizziness or fainting Anemia Irregular periods
Asthma spells
ADD Inherited blood Sexually transmitted
Pneumonia disorder (Specify) disease
Paralysis Eye trouble besides Blood transfusion
Chronic cough need glasses
Disabling depression Bone, joint, or other Alcohol use
Head or neck radiation deformity
treatments
Excessive worry or Knee problems Drug use
Tumor or cancer anxiety
(specify)
Ulcer (duodenal or Recurrent back pain Anorexia/Bulimia
Malaria stomach)
Intestinal trouble Neck injury Smoke 1+ pack
Thyroid trouble cigarettes/week
Pilonidal cyst Back injury Regularly exercise
Diabetes
Frequent vomiting Broken bone Wear seat belt
Serious skin disease (specify)
Gall bladder trouble Kidney infection Other (specify)
Mononucleosis
or gallstones
Bladder infection

Please list any drugs, medicines, birth control pills, vitamins, minerals, and any herbal/natural product (prescription and nonprescription) you use and how often you use them.

Name Use Dosage Name Use Dosage

Name Use Dosage Name Use Dosage

Check each item “Yes” or “No.” Every item checked “Yes” must be fully explained in the space on the right (or on an attached sheet).

Have you ever experienced adverse reactions (hypersensitivities, allergies, upset stomach, rash, hives, etc.) to any of the following? If yes,
please explain fully the type of reaction, your age when the reaction occurred, and if the experience has occurred more than once.

Adverse Reactions to: Yes No Explanation

Penicillin
Sulfa
Other antibiotics (name)
Aspirin
Codeine
Other pain relievers
Other drugs, medicines,
chemicals (specify)
Insect bites
Food allergies (name)

Yes No Explanation
Do you have any conditions or
disabilities that limit your physical
activities? (If yes, please describe)
Have you ever been a patient in any
type of hospital? (Specify when,
where, and why)
Has your academic career been
interrupted due to physical or
emotional problems? (Please explain)
Is there loss or seriously impaired
function of any paired organs?
(Please describe)
Other than for routine check-up,
have you seen a physician or health-
care professional in the past six
months? (Please describe)
Have you ever had any serious
illness or injuries other than those
already noted? (Specify when and
where and give details)
FAMILY HEALTH HISTORY
Has any person, related by blood, had any of the following?

Yes No Relationship Yes No Relationship Yes No Relationship

Cholesterol or blood fat Cholesterol or blood fat Cancer (type):
disorder disorder
Diabetes Diabetes Alcohol/drug problems
Glaucoma Glaucoma Psychiatric illness
Suicide

SYSTEMS REVIEW

In the past month, have you had any of the following problems?

GENERAL NERVOUS SYSTEM PSYCHIATRIC

❑ Recent weight gain; how much____ ❑ Headaches ❑ Depression
❑ Recent weight loss: how much____ ❑ Dizziness ❑ Excessive worries
❑ Fatigue ❑ Fainting or loss of consciousness ❑ Difficulty falling asleep
❑ Weakness ❑ Numbness or tingling ❑ Difficulty staying asleep
❑ Fever ❑ Memory loss ❑ Difficulties with sexual arousal
❑ Night sweats ❑ Poor appetite
❑ Food cravings
MUSCLE/JOINTS/BONES STOMACH AND INTESTINES ❑ Frequent crying
❑ Numbness ❑ Nausea ❑ Sensitivity
❑ Joint pain ❑ Heartburn ❑ Thoughts of suicide / attempts
❑ Muscle weakness ❑ Stomach pain ❑ Stress
❑ Joint swelling ❑ Vomiting ❑ Irritability
Where? ❑ Yellow jaundice ❑ Poor concentration
❑ Increasing constipation ❑ Racing thoughts
EARS ❑ Persistent diarrhea ❑ Hallucinations
❑ Ringing in ears ❑ Blood in stools ❑ Rapid speech
❑ Loss of hearing ❑ Black stools ❑ Guilty thoughts
❑ Paranoia
EYES SKIN ❑ Mood swings
❑ Pain ❑ Redness ❑ Anxiety
❑ Redness ❑ Rash ❑ Risky behavior
❑ Loss of vision ❑ Nodules/bumps
❑ Double or blurred vision ❑ Hair loss
❑ Dryness ❑ Color changes of hands or feet OTHER PROBLEMS:

THROAT BLOOD
❑ Frequent sore throats ❑ Anemia
❑ Hoarseness ❑ Clots
❑ Difficulty in swallowing
❑ Pain in jaw KIDNEY/URINE/BLADDER
❑ Frequent or painful urination
HEART AND LUNGS ❑ Blood in urine
❑ Chest pain
❑ Palpitations Women Only:
❑ Shortness of breath ❑ Abnormal Pap smear
❑ Fainting ❑ Irregular periods
❑ Swollen legs or feet ❑ Bleeding between periods
❑ Cough ❑ PMS

WOMENS REPRODUCTIVE HISTORY:

Age of first period:
# Pregnancies:
# Miscarriages:
# Abortions:
Have you reached menopause? Y / N At what age?
Do you have regular periods? Y/N
LABORATORY FINDINGS
52. Urinalysis 0 1+ 2+ 3+ 4+ 53. Blood Tests Attach Reports
Color Sugar CBC RPR Pos
Appearance Blood Normal Neg
Sp. Gravity Ketones Abnormal
Ph Bilirubin HIV Pos
Protein Sickle Cell Pos Neg
Neg

54. Pulmonary Function 55. X-rays Normal Abnormal (Describe)

FVC Chest
FEV1 Lumbar Spine
FEV1/FVC Long Bone Series
Other
56. Electrocardiogram 57. Audiogram
Static
Exercise Stress
58. Comprehensive Attach Lipid Panel Comments: 59. Drug Screen
Metabolic Panel Report (if done)
Not collected
Normal Normal Collected, results sent to employer
Abnormal Abnormal